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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-i-OFF` CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PFRMIT Permit No. i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued2' 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct. <br /> and/or install the work herein described. This application is made in compliance with San Joaquin , <br /> County Ordinance No 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT O <br /> Owner's Name Phone -7 6 ! JOL 7�� <br /> i <br /> Address City <br /> San Joa* is PLIMP Co. r <br /> Contractor s Name _sulphur Co.) License # 3 7 Phone <br /> 4. -t� " <br /> Lcdi, Caiifarnia 951 <br /> 40 <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /7 RECONDITION,//"-T DESTRUCTION /7 <br /> PUMP INSTALLATION//// PUMP REPAIR IV// PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' {Ij <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:'— State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G AND A -FINAL INSPECTIO San Joaquin PUMP CO- <br /> SIGNED <br /> 0.SIGNED oe TITLE <br /> DRAWPL T' PLAN ON RE 1tSE SIRE 'Y's'�� <br /> PHASE I <br /> QY �71Q _�s / FOR DEPARTMENT USE ONLY Lodi, Califarniu 95240 <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f DATE ` 7 E <br /> 3/76 2 <br /> E H 1426 Rev. 1-74 <br />